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INVENTORY RECONCILIATION � 1988 <br /> Psawjq <br /> QUARTERLY SUMMARY REPORT FORM JUIN 1 <br /> /� rr ENVIROMENTAL HEALTH <br /> Facility NameC7t77Z2 .���>,;;,�(� C.c)afC.G�?c'� Tank i S Product <br /> Facility Address: <br /> Telephone : �d2 ? 3 -9CeP/ <br /> Person Film <br /> Report <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank t, and amount for all variations that exceeded the <br /> allowable limits, <br /> Date Tank / Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation whichexceeded allowable limits was due to <br /> a leak the incident shall be reported to S ,J ,L .H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - _ January --> March <br /> / Q Quarter 2 - April --) June. <br /> 7 Quarter 3 - July --) September <br /> Quarter 4 - October --> December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DIS'TRIC'T' <br /> 1601 E . Hazelton , P . O . Box 2()()9 <br /> Stockton , CA 95201 466-67b1 <br /> UG"1' 40 10/86 <br />